Fighting Big Diseases With Little Computers

Digital pharmaceutical management systems, such as this one in Ethiopia, help health systems better respond to diseases like tuberculosis. Photo: Jiro Ose.

Treatments for diseases like tuberculosis (TB) and HIV are lengthy and complex. Medications need to be taken regularly and for extended periods. Interruptions come at a high cost for patients, their families, and the health systems that treat them.

Over the past several years, professionals across a range of disciplines have focused on creating solutions at all levels of the health system. From a tool that helps governments calculate the economic cost of medicine stock-outs to a piece of software that allows doctors across Ukraine to follow a patient’s complex TB treatment, technology can play a critical role in bringing solutions to scale and making significant progress in the age-old fight against deadly diseases.

Here are two examples of how MSH is helping health workers use computers to fight back.

To appreciate the importance of having these tools, you might need to be reminded of two things. First, that curing a patient of TB requires a months-long course of antibiotics whose dose and type often need adjusting over the life of the treatment. Even then, success is not guaranteed. Second, if a patient does not finish the complete course of antibiotics, he or she may develop resistance to the medicine. That “stronger” form of the illness — called multidrug-resistant, or MDR-TB — is harder to treat, and is also more contagious. This is, in part, how MDR-TB came to be, and why we’re running out of medicines to treat certain types of TB.

To deal with TB effectively, we need systems to identify it early and treat it appropriately with an uninterrupted course of medicine.

Enter the innovators from Systems for Improved Access to Pharmaceuticals and Services (SIAPS) — a USAID-funded program implemented by Management Sciences for Health that bolsters pharmaceutical management for better health outcomes. They built a web-based digital health technology called e-TB Manager that allows a country’s health system to manage all the information needed for tuberculosis control. The tool enables health workers to monitor in real time the status of TB treatment and flow of medicines by integrating data across key aspects of TB control (presumptive cases, patients, medicines, laboratory testing, diagnoses, treatments, and outcomes). e-TB Manager has been adopted by national TB control programs in 10 countries.

But they didn’t just build the technology. They worked with health ministries across those countries to train users and test, implement, and institutionalize the tool. At the end of it all, they studied user adoption and satisfaction.

Take Ukraine, where TB is among the leading cause of death among infectious diseases. According to a study by SIAPS’s Niranjan Konduri, whose research findings appear in the European Respiratory Journal Open Research, since its implementation in 2008, e-TB Manager has shown strong results: 90% of users, including doctors, nurses, and laboratory professionals, agree that it has improved patient care, and 82% say it enhances productivity.

“I once encountered a situation in the office of a Ukrainian doctor who had to approve for a hospital maternity ward to release a newborn to his TB-positive mother,” says Konduri. “Instead of making time-consuming phone calls to the patient’s district health facility, the doctor was able to swiftly review the mother’s treatment history in e-TB Manager and discover that she had developed multidrug-resistant TB. That information had not been communicated to the maternity hospital. Eventually, the doctor decided to withhold releasing the newborn to the mother until she finished her treatment to protect the baby.”

Seeing such tangible benefits, Konduri explains, goes a long way toward reducing any reluctance doctors and health workers may feel toward adopting a digital health technology.

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In addition to e-TB Manager, SIAPS has built a number of other digital health solutions to help a country’s health system better respond to TB and other diseases, to speed approval of new drugs and maintain quality control, and to prevent medication stock-outs in health facilities. These include QuanTB, RxSolution, Pharmadex, Electronic Dispensing Tool, and more.

THE ECONOMIC COST OF INTERRUPTING TB TREATMENT

Many patients interrupt medical treatment because of difficulties in obtaining medicines or because the treatment is long and difficult. In the case of TB, non-adherence to treatment results in increases in the length and severity of the illness, disease transmission, and drug resistance, all of which have economic consequences in terms of cost and loss of income for patients and their families, and cost to the health system.

But how can these interruptions be prevented? On the provider side, actions include ensuring proper prescribing practices and management of side effects, providing good quality medicines, and preventing stock-outs. Actions on the patient side include interventions to encourage patients to continue treatment even when they feel better and use medicines as directed and to remove barriers, such as transportation costs.

These actions are believed to be a good investment, but the economic savings have not been clearly defined.

A patient receives her medicines at a hospital based drug dispensary in Kenya. Photo: Mark Tuschman.

SIAPS built a simple tool to help countries to calculate the economic impact of a TB medicine stock-out and the lack of treatment adherence. Ultimately, this information can promote the benefits of investing in patient management and interventions to ensure the availability of good quality medicines and encourage patient compliance.

David Collins, an MSH senior technical advisor in the health care finance unit built the tool and applied it in the Philippines, a country with a high TB burden whose decentralized health system makes patient compliance incentives and supply chain management of drugs a challenge.

Based on the analysis, stock-outs of TB drugs in 2014 cost the Philippines an estimated USD 21 million. Patients who stopped taking their treatment cost the country an additional USD 85.6 million.

The report states, “These are probably underestimates of the economic costs because we have not taken into account all effects of non-adherence. For example, we have not included the impact of reinfection where a patient who has been partially treated and become non-infectious has then stopped treatment for long enough to become infectious again. In addition, we have not included the productivity loss related to new persons who are infected by the non-adherent patients and who then die.”

“It is clear that the cost of treatment interruption in the Philippines is significant,” says Collins. “Investing additional resources to resolve the causes of interruption is likely to be extremely worthwhile.”